Inequalities in primary care management of knee pain and disability in older adults: an observational cohort study

Objectives. To describe primary care management of knee pain, in relation to National Institute for Health and Clinical Excellence (NICE) OA guidelines, and examine variation in management by patient characteristics. Methods. Subjects were 755 adults aged ≥50 years who responded to baseline and 3-year surveys and had consulted primary care for knee pain. Medical records (1997–2006) were searched. Associations of having interventions from the outer circle (adjunctive treatments or Step 3) of the NICE guidelines with self-reported socio-demographic and knee-specific factors were determined. Results. Eighty per cent had received a Step 3 intervention. Thirty-eight per cent had been referred to secondary care, and 10% had received a knee replacement. Forty-three per cent had been prescribed an opioid and 41% an NSAID. Severe knee pain or disability at baseline and follow-up was the main association with receiving a Step 3 intervention [adjusted odds ratio (OR) 2.26; 95% CI 1.38, 3.70] and with referral (OR 2.57; 95% CI 1.72, 3.83). Older patients were less likely to be referred. Although non-significant, those of higher social class, in more affluent areas, older age or overweight or obese, appeared more likely to receive a knee replacement. Fifty per cent of those reporting severe knee pain or disability in both surveys had not been referred to secondary care. Conclusion. Most of the older adults who consult primary care with knee pain receive at least one Step 3 intervention from the OA guidelines. Inequalities in the management and referral of knee problems in primary care were generally not observed, although there were some trends towards differences in likelihood of total knee replacement.